In our study, low educational status of women was associated with a high risk of cardiovascular disease in general. This effect was attenuated in men, but the highest educated group of men still had less risk factors compared to the reference group, specifically, impaired fasting glucose, high triglyceride levels, and smoking, which is consistent with previous studies.11
However, some points need to be discussed in our study.
Firstly, educational status has a different effect on cardiovascular risk factors among men and women. We may suspect employment status as the underlying factor creating this sexual difference, because employment also is considered an important factor influencing cardiovascular risk factors.19)
According to Korean statistics,20)
educational status influences employment more in men than in women. Unfortunately, the results were not changed although adjusting employment status. From a different viewpoint, we used the same cutoff line to classify the educational status in men and women, even though the median year of education was higher in men according to our data. Consequently, the highest educated group of women corresponded to a higher degree of selection compared to that of men, which may have possibly inflated the estimates.
Secondly, there was inconsistency with a previous study,21)
in that the highest educated group was less physically active than the reference group. Our study was limited as a cross-sectional study. The causal relationship between factors cannot be determined, and reverse causality is always a possibility. For example, the highest educated group may be less motivated to exercise due to lower prevalence of other cardiovascular risk factors. Nevertheless, considering the fact that physical activity is beneficial to various medical conditions,17)
it is undeniable that physical activity in the highest educated group is insufficient.
Regarding care of diabetes mellitus, there were some significant disparities by educational status, and these findings were consistent with a previous study.22)
We observed some differences in treatment in men and achievement of glycemic control in women. However, a consistent difference was apparent in education related to disease. It is already well known that education takes an important role in diabetic care.23)
Although the guidelines recommend that all new patients receive "diabetes self-management education", only fifteen percent of participants answered that they have received diabetic education, and our results suggest that fewer among the lowest educated group receive education about disease. We could assume that the more educated group may have more opportunities to assess microvascular complications through fundus and renal screening. When we adjusted for education about diabetes, although this data was not shown, the association was no longer apparent. It suggests that the major factor to improve care is not educational status, which is an unchangeable factor of the past, but current education about disease.
Concerning exercise, the disparity between groups was minimal compared to the results of cardiovascular risk factors. We can thus assume that the major confounding factor related to exercise may be current disease status, especially diabetes mellitus.
Regarding care of hypertension, more education seemed to lead to better quality of care in men, while this tendency was attenuated in women. In our data, only 5 percent of those who had been previously diagnosed with hypertension reached the target goal of blood pressure without medication. On the contrary, the association between medication use and diabetic control appears to be weak. Our data suggest that the adherence to physician's orders may be more important in hypertension than self-awareness.24
Conclusively, education may have the effect of increasing adherence to physician's orders in men, while decreasing adherence in women, even though the effect appeared to be statistically insignificant.
According to a previous study,26)
these disparities might be associated with a knowledge gap. Misconception that cardiovascular disease is not preventable was frequently shown in less educated people, and this could impede modification of lifestyle and receipt of proper care. High risk and poor care, interacting viciously among the lowest educated group, may be associated with increased mortality.27)
Health care and education about disease provided by educational status are expected to contribute to lower advanced disease and mortality effectively.
Conclusively, we found that there were educational disparities in cardiovascular risk factors and care of hypertension and diabetes mellitus. The disparities were found to be different by gender.